Provider Demographics
NPI:1548730799
Name:ZANDER, JESSE
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:ZANDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3595 COUNTY ROAD K
Mailing Address - Street 2:
Mailing Address - City:BARNEVELD
Mailing Address - State:WI
Mailing Address - Zip Code:53507-9797
Mailing Address - Country:US
Mailing Address - Phone:608-317-9820
Mailing Address - Fax:
Practice Address - Street 1:600 2ND AVE
Practice Address - Street 2:
Practice Address - City:NEW GLARUS
Practice Address - State:WI
Practice Address - Zip Code:53574-9776
Practice Address - Country:US
Practice Address - Phone:608-527-4390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2885-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant